A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
Sit at or below the client's eye level during feedings.
Instruct the client to lift her chin when swallowing.
Talk with the client during her feeding.
Discourage the client from coughing during feedings.
The Correct Answer is A
Rationale:
A. Sit at or below the client's eye level during feedings: Positioning the nurse at or slightly below the client’s eye level promotes effective communication and allows close observation of swallowing. It helps the nurse monitor for signs of aspiration, coughing, or choking, which is critical in clients with dysphagia to ensure safety during meals.
B. Instruct the client to lift her chin when swallowing: Clients with dysphagia should be taught to tuck the chin slightly toward the chest, not lift it, to protect the airway and facilitate safer swallowing. Lifting the chin increases the risk of aspiration and airway compromise.
C. Talk with the client during her feeding: Talking while swallowing increases the risk of aspiration because it distracts the client and can disrupt coordinated swallowing. Silence and focused attention are recommended during feeding to ensure safe intake of food and liquids.
D. Discourage the client from coughing during feedings: Coughing is a protective reflex that clears the airway if food or liquid enters the trachea. Discouraging it could increase the risk of aspiration and choking, making it unsafe to suppress this natural defense mechanism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Administer the medication into the vastus lateralis muscle: The vastus lateralis is the preferred site for intramuscular injections in infants because it is well-developed and free of major nerves and blood vessels. This site allows for safe and effective absorption of the medication.
B. Administer the medication with a 20-gauge needle: A 20-gauge needle is too large for infants and can cause unnecessary tissue trauma. A smaller gauge, typically 22–25, is appropriate for IM injections in infants to minimize pain and tissue damage.
C. Administer the medication into the deltoid muscle: The deltoid muscle is underdeveloped in infants, making it unsuitable for IM injections due to limited muscle mass and risk of injury to underlying structures. It is generally used only in older children or adults.
D. Administer the medication over 2 min: IM injections are typically administered at a moderate pace, but a 2-minute administration is unnecessarily slow for infants. Proper technique involves steady, controlled injection without causing excessive discomfort.
Correct Answer is C
Explanation
Rationale:
A. Remove the client's catheter: Removing the catheter could allow more air to enter the circulation and worsen the embolism. The priority is to prevent further air entry while stabilizing the client, not immediate removal of the line.
B. Prepare the client for chest tube insertion: Chest tubes are used for pneumothorax or pleural effusions, not for treating an air embolism. Immediate positioning and oxygen therapy are the primary interventions.
C. Place the client in a left-lateral Trendelenburg position: Positioning the client in the left-lateral Trendelenburg (head down, left side down) traps air in the right atrium and prevents it from entering the pulmonary circulation, reducing cardiovascular compromise. This is the recommended first intervention for a suspected air embolism.
D. Instruct the client to perform the Valsalva maneuver: Performing the Valsalva maneuver increases intrathoracic pressure and may temporarily help, but it is not the first priority. Proper positioning and immediate oxygen administration are more critical to prevent complications.
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